Consultant, training and author in behavioral health.

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Instilling Hope in a First Session

I’m starting a new placement next month, and I want to know how to be as helpful as possible in my client sessions. How can I handle the first session so they are likely to want to come back and continue therapy?

Starting your first placement is a big step and one that most clinicians approach with some amount of anxiety as well as excitement. It’s a good idea to start by thinking about the first session with clients and how to engage them from the beginning. There is a lot to do in a first session–getting informed consent, establishing a therapeutic alliance, following the client’s story, beginning an assessment, and responding to the client’s wishes and goals–and chapter 3 of my book covers this topic. Communicating empathy and understanding is crucial in the first session as clients share their distress and pain. They are motivated to continue therapy when they have a feeling of hope in the therapeutic process. In this blog, I will describe two ways to instill hope during the first session.

First, clients feel hopeful when they have an awareness of their strengths, which provides confidence that they can face and overcome their difficulties. It is important to hold a “both/and” perspective in talking about strengths, reflecting that you understand the seriousness of the clients’ concerns and problems while also pointing out the capabilities reflected in their life stories. Most often, clients enter therapy feeling discouraged and self-critical. Feelings of shame and fear are common, whether their symptoms are new, have occurred at other times, or have been ongoing. There are a number of ways to identify and highlight the client’s strengths, depending on the initial presentation and the flow of the session. When the client leads with a description of what isn’t working and how their life has been impacted negatively, you can ask how they have coped with this difficult situation and support whatever positive coping strategies they report using. An example is “It’s impressive that you’ve been able to connect with a friend at least once a week, even though your depression has interfered with your appetite and sleep and your mood has been very low.” You can also ask about different areas of the client’s life and contrast areas of success with areas that are more problematic by saying, for example, “It sounds like your anxiety has made it hard to speak up in meetings at work, but you were able to advocate for your daughter to get the help she needed at school.” It also helps to reflect the client’s statements of strength in addition to reflecting and empathizing with their problems.

Second, clients need to leave a first session with a sense of hope in and direction for the therapy. I use the last 5-10 minutes of the first session for this purpose, including asking the client how it has been to talk about her concerns, summarizing how I would anticipate working together on her presenting issues, and expressing confidence that therapy can be helpful. I emphasize the collaborative nature of therapy by using terms like “working together” or “what we might look at,” and I provide a realistic assessment of the uncertainty and difficulty of changing longstanding patterns along with my belief that things can improve. A short summary statement is “If you want to continue working together, I would recommend looking at the emotions that have led to your outbursts of anger and how you can develop different ways to express those emotions before they become really intense. I know you’ve avoided the fear and sadness we talked about very briefly today, but I believe those emotions are related to the anger outbursts. You said your goal is to reduce your anger, and if you’re willing to look at those other emotions as you’re ready, I think you’ll be able to do that.”

If you keep these two strategies in mind in your first session with clients, I believe you’ll help them feel hopeful about continuing to work with you in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.